Provider First Line Business Practice Location Address:
2064 MARENGO ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90033-1353
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-576-2250
Provider Business Practice Location Address Fax Number:
323-576-2252
Provider Enumeration Date:
04/14/2023